Application of the AHA/ACC/HFSA Heart Failure Staging Guidelines in CKD

Background: The 2013 American Heart Association (AHA)/ American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) Guidelines for the Management of Heart Failure (HF) proposed a staging system to diagnose HF and its severity, ranging from A to D. In 2022, these guidelines were updated to include the use of cardiac biomarkers. The effect of this HF staging system in CKD is not well established. Methods: 2415 participants from the Chronic Renal Insufficiency Cohort were classified into HF stages using 2013 and 2022 guidelines. Echocardiographic changes and cardiac biomarkers (troponin T ≥10 ng/L in females, ≥15 ng/L in males or pro-brain natriuretic peptide ≥125 pg/mL) were utilized in staging. Incidence rates and 95% CIs for HF hospitalizations and all-cause death during follow-up were calculated. Results: Only 4.8% of CKD participants were classified as "healthy” using either staging guideline. The inclusion of cardiac biomarkers in the 2022 guideline reclassified 55% (n=469) of 2013 guideline Stage A participants to Stage B. Participants with lower eGFRs were more likely to be reclassified (Table 1). Using 2022 guidelines, the incidence of HF hospitalization in Stage B differed when based on biomarkers (1.7 per 100 person-yrs, 95% CI 1.3-2.1) compared to echocardiographic abnormalities (2.9 per 100 person-yrs, 95% CI 2.6- 3.3) whereas death rates were similar between these groups (Figure 1). Conclusion: Among large CKD cohort, only 20% of participants met the criteria for “healthy” or “at risk” for HF. There was high reclassification of CKD participants into more advanced HF stages with the addition of cardiac biomarkers. Differing HF hospitalization incidence rates between those classified based on biomarkers alone compared to echocardiographic abnormalities suggest reclassification may not reflect true HF status. CKD-specific thresholds for cardiac biomarkers may be useful to improve accuracy of HF staging in CKD.